Policy Brief

JULY 2015

BY KATE GILLES INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION

Intimate partner violence (IPV)—physical and/or BOX 1 sexual violence by a current or former partner—is an issue that women in all regions and all countries experience (see definition, Box 1).1 Globally, DefiningIntimate 1 in 3 approximately one in three women who have ever Partner Violence (IPV) The share of women been in a relationship have experienced IPV.2 worldwide who have Women face a greater risk of violence from an Intimate partner violence (IPV) refers to physical experienced intimate 3 and/or sexual violence by a current or former partner violence. intimate partner than from anyone else. partner. Physical and sexual violence often This brief presents data to help policymakers and occur together, though not always, and can others understand the nature and extent of the happen in the context of marriage or less formal relationships (including dating or unmarried sexual harm caused by IPV, especially as it relates to relationships). IPV can affect men and women women’s reproductive health and autonomy, and Unintended pregnancy alike, but most frequently women experience is more common among highlights opportunities for action. Policymakers IPV at the hands of male partners. women who have can combat IPV and its consequences by experienced intimate promoting integrated policies and dedicating Source: World Health Organization (WHO), Global and Regional partner violence financial resources to support systems, programs, Estimates of Violence Against Women: Prevalence and Health Effects compared to those of Intimate Partner Violence and Non-Partner Sexual Violence (Geneva: and services to address the intersection of IPV, WHO, 2013); and WHO, Preventing Intimate Partner and Sexual who have not. health, and women’s empowerment. Violence Against Women: Taking Action and Generating Evidence (Geneva: WHO, 2010). Intimate Partner Violence Is a Global Epidemic FIGURE 1 2X Higher The highest rates of IPV are found in Africa, the IPV Occurs Among Women of All Ages The difference in induced eastern Mediterranean, and Southeast Asia— abortion rates between approximately 37 percent of women in each Percent of Ever-Partnered Women Who Have Experienced IPV women who have of those regions, compared to 23 percent in 37.8 experienced intimate high-income regions.4 Some women may be 36.6 partner violence and especially vulnerable to IPV and the associated 32.3 those who have not. 31.6 31.1 negative consequences, including young women 29.4 29.2 and women in crisis or conflict settings (see Figure 1; see Box 2).5 Other factors that increase a woman’s risk of IPV include early marriage, partner’s alcohol abuse, and witnessing domestic violence as a child.6

IPV imposes significant health and rights consequences on women, including poor physical, mental, and reproductive health, and on their infants and children, who are at greater risk for a variety of poor health and development 15–19 20–24 25–29 30–34 35–39 40–44 45–49 outcomes. The negative effects of IPV extend to Age national development that is hampered by lost Sources: World Health Organization (WHO), Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate productivity and increased health and other social Partner Violence and Non-Partner Sexual Violence (Geneva: WHO, 2013). services costs. BOX 2 BOX 3 IPV Among Adolescent Girls Addressing IPV Within a and Young Women Rights-Based Approach to

IPV is a common experience among adolescent girls and young Reproductive Health women. Among those who have ever been in a relationship, 29 percent of 15-to-19-year-old girls and 32 percent of The growing emphasis on a rights-based approach to 20-to-24-year-old young women have experienced physical reproductive health care promotion and provision presents or sexual violence from a partner. These figures are especially a key opportunity to address the negative impact of IPV. It is alarming since early sexual and relationship experiences a violation of multiple human rights, including the right to life are a significant influence on a woman’s future: The effects and security of the person, the right to equality, and the right 1 of violence during this formative period on a woman’s long- to the highest attainable standard of health. A rights-based term health and well-being may be magnified. Since women approach to family planning and reproductive health accounts who experience one instance of partner violence are likely to for the full range of barriers that may interfere with a woman’s experience more, violence at a young age may increase ability to make free, informed, and voluntary decisions about a woman’s overall lifetime exposure.1 her reproductive health and behavior, including contraceptive use.2 Seen through this lens, addressing IPV is a strategy for Adolescent girls and young women may be at heightened enabling otherwise disempowered women to gain some control risk for IPV because of their youth, relative inexperience, and over one aspect of their lives. gendered power dynamics, especially if the male partner is 1 World Health Organization (WHO), Responding to Intimate Partner Violence and 2 older. Though IPV frequently occurs outside of marriage, early Sexual Violence Against Women: WHO Clinical and Policy Guidelines (Geneva: marriage is a particular risk factor. WHO, 2013).

1 Heidi Stöckl et al., “Intimate Partner Violence Among Adolescents and Young 2 Family Planning 2020, “Rights and Empowerment Principles for Family Planning,” Women: Prevalence and Associated Factors in Nine Countries, A Cross-Sectional (2014), accessed at www.familyplanning2020.org/resources/4697 on May 20, 2015. Study,” BMC Public Health 14, no. 751 (2014); Michelle Decker et al., “Gender- Based Violence Against Adolescent and Young Adult Women in Low- and Middle- Income Countries,” Journal of Adolescent Health 56 (2015): 188-96; and World Health Organization (WHO), Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence (Geneva: WHO, 2013). and a violation of human rights (see Box 3).9 Increasingly, IPV is 2 WHO, Preventing Intimate Partner and Sexual Violence Against Women: Taking also being recognized as a health issue, especially reproductive Action and Generating Evidence (Geneva: WHO, 2010). health.10 Awareness is still limited regarding the relationship between IPV and reproductive health and the appropriate role of policymakers and health care providers in identifying, responding to, and supporting women experiencing IPV. Some of the most severe consequences of IPV are related to women’s reproductive health and empowerment. These outcomes include higher rates of unplanned pregnancy, IPV: Wide-Ranging Consequences abortion, and miscarriage, suggesting that IPV often interferes Women who experience IPV are at greater risk of a range of poor with women’s ability to consistently use effective contraception. health conditions and outcomes (see Figure 2, page 3 ). They are twice as likely to experience depression as women who have not Bringing IPV Into the Open experienced IPV, and up to one and a half times more likely to become HIV positive.11 Other negative health outcomes include IPV is often treated as a private matter, ignored, or even seen injury, gastrointestinal problems, chronic pain, depression, as normal or acceptable. Frequently, women do not report posttraumatic stress disorder, suicide, and alcohol use.12 abuse by an intimate partner out of fear of retaliation or stigma, the belief that violence from partners is expected, or the feeling IPV also has serious consequences for infants and children: that no one can or will help them.7 Violent behavior in general Women in violent relationships are less likely to receive and violence towards a partner in particular are often seen as adequate prenatal care and more likely to have a preterm normal, acceptable masculine behaviors. These attitudes are birth or low birth-weight baby. Children of women who learned early on, and boys and girls who witness household experience IPV are less likely to receive immunizations and abuse often carry those behaviors into the next generation.8 may be at increased risk of additional health, developmental, and behavioral problems later in life.13 Moreover, children who Only within the past few decades has IPV (along with other witness violence in their home are significantly more likely to types of violence against women) come to be seen as a crime perpetrate or experience violence themselves later in life.14

2 www.prb.org INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION HIV and other sexually transmitted infections (STIs), or insist on FIGURE 2 contraception.18 IPV is sometimes accompanied by reproductive Pathways and Health Effects of Intimate Partner Violence coercion, in which a male partner directly interferes with a woman’s desires for her pregnancy (see Box 4).19 The controlling INTIMATE PARTNER VIOLENCE behavior that often characterizes violent relationships can constrain a woman’s access to health care, including family FEAR AND planning, and exacerbate health problems associated with IPV.20 CONTROL Women who experience IPV also experience higher rates LIMITED SEXUAL HEALTH CARE of unintended pregnancy.21 A study in Colombia estimated AND REPRODUCTIVE SEEKING that stopping IPV in that country would prevent over 32,000 CONTROL • lack of autonomy 22 • lack of contraception • difficulties seeking care unintended pregnancies every year. • unsafe sex and other services Rates of induced (often unsafe) abortion are also higher— by some estimates, more than double—among women who experience IPV, reflecting the high rates of unintended 23 PERINATAL/MATERNAL SEXUAL AND pregnancies. Women in violent relationships also experience HEALTH REPRODUCTIVE higher rates of miscarriage and stillbirth.24 • low birth weight HEALTH • prematurity • unwanted pregnancy • pregnancy loss • abortion • other STIs IPV and Family Planning: • gynecological problems A Complicated Picture Given the high rates of unintended pregnancy and poor reproductive health outcomes among women exposed to DEATH IPV, it is important to consider the relationship between IPV DISABILITY • homicide • suicide • other and family planning. The impact of IPV on contraceptive use is complicated and varies across countries and settings.

Source: Adapted from World Health Organization (WHO), Global and Regional Estimates Longitudinal studies—that is, studies with data from more of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and than a single point in time—can help explain the relationship Non-Partner Sexual Violence (Geneva: WHO, 2013). between IPV and family planning and determine whether IPV makes it more or less likely that women will use contraception. The accumulated impact of IPV on individual women’s well- One analysis of longitudinal studies in developed countries being translates into negative consequences for communities found evidence that women who experienced IPV within and nations. Direct costs in the form of increased health care and social service expenditures represent a significant burden to national budgets. For example, the annual estimated cost of expenses related to IPV is between US$1.7 billion and US$10 BOX 4 billion in the United States.15 Additional economic costs are accrued when women miss days of work or are prevented from working outside the home: Estimates from Brazil, Tanzania, Chile, Reproductive Coercion and South Africa place lost productivity due to IPV at 1 percent Silverman and Raj define reproductive coercion as “…behav- to 2 percent of gross domestic product.16 Total annual costs iors that directly interfere with contraception and pregnancy, of IPV are estimated at almost 23 billion pounds in the United reducing female reproductive autonomy. The two forms of Kingdom and the equivalent of 4.5 billion pounds in Australia.17 reproductive coercion are pregnancy coercion and contra- Though these are the most recent calculations, they are a ception sabotage.” Pregnancy coercion refers to efforts by a number of years old and likely underestimate the actual costs. male partner to force a woman to become pregnant or carry a pregnancy to term when she does not wish to or, conversely, to end a pregnancy against her will. Contraception sabotage IPV: A Reproductive Health Issue describes intentional interference by a male partner with a woman’s attempts to prevent pregnancy, for example hiding Some of the most severe consequences of IPV are related or destroying pills or breaking a condom. to women’s reproductive health and autonomy. In a global review, the World Health Organization (WHO) notes that, Source: Jay G. Silverman and Anita Raj, “Intimate Partner Violence and Reproductive Coercion: Global Barriers to Women’s Reproductive Control,” PLOS Medicine 11, no. 9 “Women in violent relationships, or who live in fear of violence, (2014): e1001723. may…have limited control over the timing or circumstances of sexual intercourse…” Women exposed to IPV may not be able to choose when to have sex, protect themselves from

INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION www.prb.org 3 the past 6 months to 12 months were less likely to use all settings, even when reported contraceptive use is high, it is contraception, particularly condoms.25 Unfortunately, few reasonable to assume that IPV interferes with women’s ability longitudinal studies have been done in developing countries. to effectively and consistently use contraception.33 It also indicates that current family planning resources and services Available data for developing countries paint a complicated are not meeting the needs of women in violent relationships. and context-dependent picture: Some studies have found that women who experience IPV are less likely to use modern methods of contraception, while other studies have found similar A Window of Opportunity or higher rates of contraceptive use among women reporting The vast majority of women—including those who experience IPV, as compared to those who do not report.26 Other studies IPV—will use reproductive health care services at some point have found that women subject to abuse are more likely to have in their lives. Studies have shown that women are willing to used contraception at some point, but are also more likely to disclose and receive support from health care providers. stop using contraception and are less likely to use their preferred Universal screening—assessing all women for IPV during method, suggesting that IPV interferes with women’s ability to a health care visit, regardless of whether she presents any consistently use their preferred method over time.27 indications she has experienced or is at risk of experiencing IPV—may not be feasible or appropriate in settings where More research is needed to explain the reasons for these women cannot be offered or referred to comprehensive variations, but a few factors seem to influence whether a support services.34 However, even when active screening is woman experiencing IPV is motivated and able to use family not implemented, providers are often the first to recognize or planning. Those include: be told about abuse. Recognizing this, WHO recommends that • Gender norms. Where gender norms are more rigid regardless of screening protocol, all providers be trained to offer 35 and male authority or dominance is strongly enforced, compassionate, woman-centered care (see Box 5, page 5). women have less autonomy overall. In this context, women Recognizing the realities of women in violent relationships is in violent relationships may be even less able to use essential to providing them with appropriate care that meets contraception.28 their particular needs. This care includes helping a woman • Community acceptance of contraceptive use. Where choose a contraceptive method that she can use easily, safely, modern contraception is widely used, it may be more and effectively; offering other essential reproductive health acceptable and easier for women experiencing IPV to use services, like STI and HIV screening and treatment, antenatal family planning.29 If contraception is not widely used in the care, and maternal health services; and connecting women woman’s community, however, a woman may be afraid to other resources where available, such as psychosocial that using contraception will be seen as a transgression of counseling, social services, and legal counsel.36 accepted behavior, putting her at risk of violent retaliation from her partner. The type of methods that are most The health care system needs to be equipped to offer commonly used in a community may also influence use. For compassionate support and tailored care for women example, the most common methods in India are condoms experiencing IPV, with providers trained in woman-centered and female sterilization, but condoms require a partner’s care, adequate staffing levels, supportive supervision, cooperation, which may not be possible for women in standardized protocols, and linkages to broader systems violent relationships, and sterilization is permanent, which of support for women exposed to violence. Putting all may not meet the needs of all women.30 these pieces in place requires political action and financial commitment. • Availability of contraception. When contraception is more widely available, affordable, and accessible—for Policymakers Are Critical Partners example, through strong government family planning programs or community-based distribution—it may be for Meeting the Needs of Women easier for women to use, even when their autonomy is Experiencing IPV limited by partner violence.31 Policymakers can establish the policy framework and financial • Type of IPV. A few recent studies have shown that women commitments to enable family planning and reproductive health experiencing sexual violence from a partner are more likely to programs to reach women experiencing IPV with appropriate use contraception, and more likely to use a female-controlled services and supportive tailored care. Policies and dedicated method, than women experiencing physical partner violence funding to support integrated and effective approaches to or women not experiencing partner violence at all.32 IPV response and family planning provision should include the development of comprehensive health system guidelines, training Given that unintended pregnancy and induced abortion are for providers, adequate staffing, strong supply chains to ensure more common among women experiencing IPV across nearly the full range of contraceptive methods is available, and strong

4 www.prb.org INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION referral networks and support services for women in violent relationships. BOX 5 At the same time, policymakers can complement and strengthen the work of the health sector by introducing and Training Health Care Providers supporting critical strategies to prevent and reduce IPV broadly. Since IPV is strongly linked to inequitable gender in IPV Response and Woman- attitudes and harmful beliefs about men’s and women’s Centered Care roles, this support includes implementing initiatives across sectors that promote gender equality and transform Ideally, providers will receive training throughout their careers, negative gender norms—in schools and youth sports from preservice to regular in-service training. Basic training programs, through mass media campaigns, or in economic for IPV response and support should include sensitizing providers and improving their understanding of the causes of development programs.37 Policymakers can foster linkages IPV, improving knowledge of the connection between IPV and across the health care system, social services, the police health so providers can tailor their care to the specific needs of and judiciary, the education system, and other sectors to women, and connecting providers to other available resources promote a coordinated response to IPV. for women experiencing IPV.1

This basic training is foundational for woman-centered care, Promising Approaches defined by WHO as: Given the tremendous toll on women, families, and countries, • Being nonjudgmental and supportive. are there promising approaches for preventing IPV? Encouragingly, yes, and as Michau and colleagues write in • Providing practical care and support that responds to the the Lancet, “Evidence shows that changes in attitudes and woman’s concern. behaviors do not need a generation, but can be achieved within shorter timeframes…”38 • Asking about her history of violence, listening carefully, but not pressuring her to talk.

CHARM: WORKING WITH MEN TO DECREASE IPV • Helping her access information about resources. AND SUPPORT WOMEN’S USE OF CONTRACEPTION • Assisting her to increase safety for herself and her children, CHARM (Counseling Husbands to Achieve Reproductive where needed. health and Marital equity) supports contraceptive use and • Providing or mobilizing social support. gender equity among young married couples by working with husbands in rural India. Specially-trained, local male • Ensuring privacy and confidentiality. village health providers (VHPs) meet with young husbands in the program for two sessions to provide counseling and 1 Julia Kim and Mmatshilo Motsei, “’Women Enjoy Punishment’: Attitudes and Experiences of Gender-Based Violence Among PHC Nurses in Rural South Africa,” education on family planning and gender equity, such as Social Science and Medicine, 54 (2002): 1243–54. shared responsibility for family planning, respectful joint decisionmaking with wives, and equal valuation of girl and boy children. VHPs emphasize the importance of valuing and respecting women and girls generally, rather than talking about gender-based violence (GBV) directly. At an additional • Less likelihood to agree that physical IPV is sometimes session, VHPs counsel couples on family planning and joint justified or to endorse sexual IPV. decisionmaking and provide family planning services. Based on these encouraging results, the researchers are A recent rigorous randomized control trial of the intervention hoping to expand and scale up the program in different showed promising results. CHARM participants, as compared settings.39 to those who did not receive the intervention, showed: SASA! MOBILIZING CHANGE IN COMMUNITIES • Improvements in both modern contraceptive use and marital communication around contraceptive use. The greatest SASA! was developed primarily as an HIV prevention increase was seen for condom use, likely because of the intervention in Uganda, but the program’s holistic approach intervention’s focus on men. to promoting gender equality and reducing violence resulted in significant impacts on a wide range of indicators, including • Significantly lower incidence of sexual IPV, making this the IPV. SASA! sought to shift community attitudes, norms, and first study to document a significant positive impact on behaviors related to gender equality and health behaviors sexual IPV. by engaging a broad range of community stakeholders in

INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION www.prb.org 5 mobilization and advocacy activities. A rigorous evaluation— and the media. This plan has been translated into a strong one of the first for an intervention of this kind—found that in framework for implementation through the health care system: SASA! communities: • The National Health System portfolio includes care for • Women were less likely to report physical IPV in the past year. women affected by violence, with technical support, coordination, and accountability provided by a special • Men were less likely to report concurrent partners in the commission. past year. • A standardized protocol to guide the health system response • Both men and women were more likely to have progressive to GBV was produced that can be adapted to specific attitudes (reduced acceptance of men’s use of violence regional contexts and includes information on local resources. against a partner and increased acceptance of a woman’s right to refuse sex). • Training is offered for providers throughout the health system, including continuous workplace-based training, and funded Other results indicate that the program had a positive impact by the Regional Health Services and Ministry of Health. on the occurrence of sexual IPV and on men’s attitudes about their right to demand sex from their partner. Most The coordination of activities across sectors and institutions is a encouragingly, these results were seen across the community, major strength of the Spanish strategy, but structural conditions not just among individuals intensely involved with the program, in the health care system still need improvement, such as which holds great promise for achieving broad societal change reducing caseloads to ensure that providers have sufficient time in a relatively short time frame.40 to spend with each patient, and guaranteeing sufficient ongoing financing for training, supervision, and other support resources. EMPOWER PROJECT: LAYING THE POLICY FOUNDATION FOR IPV RESPONSE IN BENIN Compelling Actions

From 2007 to 2012, under the EMPOWER project, CARE Benin The consequences of IPV are not limited to the home and worked to improve the anti-GBV policy and legal framework the response cannot be either. Policymakers in all sectors— in Benin. The EMPOWER project convened a network of education, finance, health, judicial, and others—can take stakeholders from civil society, ministries, communities, and the steps to address IPV, especially in family planning/reproductive media to raise awareness of GBV and push for the passage health programs and services. of the nation’s first anti-GBV law. One key to the successful passage of the new law was the simultaneous mobilization and MULTISECTORAL POLICY ACTIONS sensitization of communities, which created a groundswell of grassroots support for action against GBV. • Improve and enforce legal protections and support for women. In countries where they are nonexistent or weak, By convening partners at the community and national level, legal protections and recourse for women experiencing IPV CARE was able to build a strong platform for intensive must be introduced. In countries where laws are already on advocacy and social mobilization, and Benin’s anti-GBV the books, they must be consistently and rigorously enforced. law was enacted in 2012. In his speech welcoming the bill, the former vice president of the National Assembly cited the • Develop policies that take an integrated approach to EMPOWER project and implicitly recognized that there would IPV and health, including family planning. Ensure that be more work to do to realize the promise of the new law, IPV is specifically addressed in national health care policies saying, “EMPOWER planted a tree to be watered for the well- and programs, including those related to family planning, being of the people.”41 and that family planning and health care are explicitly incorporated into violence prevention and response policies An Integrated Policy Strategy and plans. Back up policy commitments with budgetary and resource allocations across all relevant sectors. for Improving the Response of Public Health Systems • Provide political and financial backing for initiatives that promote gender equality broadly. Support the Spain offers an example of carefully crafted policies that integration of gender equality initiatives into programs and promote an integrated response to violence against women. policies across sectors through political commitments The country has a robust policy and legal framework, including and concrete budget allocations. This support includes an anti-GBV law that requires the provision of GBV services in funding to incorporate gender equality into school health the Regional Health Service, and a national GBV awareness and life skills curricula, women’s economic empowerment and prevention plan that specifies the role and responsibilities programs, and community mobilization activities. of multiple sectors, including judicial, social services, education,

6 www.prb.org INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION HEALTH-SECTOR SPECIFIC ACTIONS 7 Claudia Garcia-Moreno et al., “Addressing Violence Against Women: A Call to Action,” Lancet 385, no. 9978 (2014): 1685-95; Olalekan A. Uthman, Stephen Lawoko, and Tahereh Moradi, “Factors Associated with Attitudes • Ensure that health care services are accessible and Towards Intimate Partner Violence Against Women: A Comparative Analysis appropriate for women experiencing IPV. Eliminate legal of 17 Sub-Saharan Countries,” BioMed Central 9, no. 14 (2009); Joanna and logistical barriers that may be especially burdensome Crichton, Celestine Musembi, and Anne Ngugi, “Painful Tradeoffs: Intimate- for women experiencing IPV, such as partner consent Partner Violence and Sexual and Reproductive Health Rights in Kenya,” (2008), working paper no. 312, Institute of Development Studies, accessed requirements and cost. Ensure the availability of a full at http://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/4171/ range of methods, especially female-controlled and long- Wp312.pdf?sequence=1, on June 30, 2015. acting methods that can be used by a woman without the 8 Tanya Abramsky et al., “What Factors Are Associated With Recent Intimate cooperation of her partner. Partner Violence? Findings From the WHO Multi-Country Study on Women’s Health and Domestic Violence,” BMC Public Health 11, no. 109 (2011); Michelle J. Hindin, Sunita Kishor, and Donna L. Ansara, Intimate Partner • Allocate funds for adequate and continuous training Violence Among Couples in 10 DHS Countries: Predictors and Outcomes, and key resources for health care providers to care DHS Analytical Studies, no. 18 (Calverton, MD: ICF Macro, 2008); Sunita for women experiencing IPV. Training for providers is Kishor and Kiersten Johnson, Profiling Domestic Violence: A Multi-Country Study (Calverton, MD: ORC Macro, 2004); National Population Commission, critical to reduce harmful attitudes about IPV, increase Nigeria, and ICF International, Gender in Nigeria: Data From the 2013 sensitivity to individuals experiencing abuse, improve Nigeria Demographic and Health Survey (Rockville, MD: National Population awareness of the relationship between IPV and health, and Commission and ICF International, 2014); H. Stöckl et al., “Intimate Partner Violence Among Adolescents and Young Women: Prevalence and build skills to offer tailored, woman-centered care. Additional Associated Factors in Nine Countries: A Cross-Sectional Study,” BMC Public resources should be allocated to ensure that staffing levels Health 14, no. 751 (2014); Emma Fulu, et al., “Prevalence of and Factors and supervisory support are sufficient to enable healthcare Associated With Male Perpetration of Intimate Partner Violence: Findings From the UN Multi-Country Cross Sectional Study on Men and Violence in providers to implement training in their day-to-day practice, Asia and the Pacific,” Lancet Global Health 1, no. 4 (2013): 187-207. and that providers can refer women to other relevant IPV 9 Mala Htun and S. Laurel Weldon, “The Civic Origins of Progressive Policy services as available. Change: Combatting Violence Against Women in Global Perspective,” American Political Science Review 106, no. 2 (2012): 1975-2005. Acknowledgments 10 Charlotte Watts and Susanna Mayhew, “Reproductive Health Services and Intimate Partner Violence: Shaping a Pragmatic Response in Sub-Saharan This publication was authored by Kate Gilles, senior policy Africa,” Guttmacher Institute 30, no. 4 (2004): 207-13. analyst at Population Reference (PRB), with extensive input 11 WHO, Global and Regional Estimates of Violence Against Women. from Charlotte Feldman-Jacobs, associate vice president 12 WHO, Global and Regional Estimates of Violence Against Women; Karuna and program director, Gender, at PRB, and edited by Heidi S. Chibber and Suneeta Krishnan, “Confronting Intimate Partner Violence: A Worley, senior writer/editor at PRB. Special thanks to Michal Global Health Priority,” Mount Sinai Journal of Medicine 78, no. 3 (2011): 449- Avni and Joan Kraft of USAID and to Sunita Kishor of ICF 57. International for their review and feedback, and to Adriana 13 WHO, Global and Regional Estimates of Violence Against Women; WHO/ Zinn, PRB intern, for her assistance with background research. London School of Hygiene and Tropical Medicine, “Preventing Intimate Partner and Sexual Violence Against Women: Taking Action and Generating Evidence,” (Geneva: WHO, 2010). This publication was made possible by the generous support 14 Stephanie Perlson and Margaret Greene, “Addressing the Intergenerational of the American people through the United States Agency for Transmission of Gender-Based Violence: Focus on Educational Settings,” International Development under the terms of the IDEA Project (Atlanta: CARE, 2014); WHO/London School of Hygiene and Tropical (No. AID-OAA-A-10-00009). The contents are the responsibility Medicine, “Preventing Intimate Partner and Sexual Violence Against Women;” of the Population Reference Bureau and do not necessarily Paul J. Fleming, et al., “Risk Factors for Men’s Lifetime Perpetration of Physical Violence Against Intimate Partners: Results From the International reflect the views of USAID or the United States government. Men and Gender Equality Survey (IMAGES) in Eight Countries,” PLoS One 10, no. 3(2015): e0118639; Ruth Levtov et al., State of the World’s Fathers: A © 2015 Population Reference Bureau. All rights reserved. MenCare Advocacy Publication (Washington, DC: Promundo, Rutgers, Save the Children, Sonke Gender Justice, and the MenEngage Alliance, 2015). 15 Monica Modi, Sheallah Palmer, and Alicia Armstrong, “The Role of Violence References Against Women Act in Addressing Intimate Partner Violence: A Public Health Issue,” Journal of Women’s Health 23, no. 3 (2014): 253-9. 1 Intimate partner violence can and often does include emotional abuse, but there is not currently an agreed-upon definition of what constitutes emotional 16 Garcia-Moreno et al., “Addressing Violence Against Women.” abuse and many studies measure only physical and sexual violence. 17 Garcia-Moreno et al., “Addressing Violence Against Women.” 2 World Health Organization (WHO), Global and Regional Estimates of Violence 18 WHO, Global and Regional Estimates of Violence Against Women; Garcia- Against Women: Prevalence and Health Effects of Intimate Partner Violence Moreno et al., “Prevalence of Intimate Partner Violence”; WHO/London School and Non-Partner Sexual Violence (Geneva: WHO, 2013). of Hygiene and Tropical Medicine, “Preventing Intimate Partner and Sexual 3 Claudia Garcia-Moreno et al., “Prevalence of Intimate Partner Violence: Violence Against Women”; Kishor and Johnson, Profiling Domestic Violence. Findings From the WHO Multi-Country Study on Women’s Health and 19 Jay G. Silverman and Anita Raj, “Intimate Partner Violence and Reproductive Domestic Violence,” Lancet 368 no. 9543 (2006): 1260-9. Coercion: Global Barriers to Women’s Reproductive Control,” PLOS Med 11, 4 WHO, Global and Regional Estimates of Violence Against Women. no. 9 (2014): e1001723. 5 WHO, Global and Regional Estimates of Violence Against Women; 20 Family Planning 2020, “Rights and Empowerment Principles for International Rescue Committee, Let Me Not Die Before My Time: Domestic Family Planning,” (2014), accessed at www.familyplanning2020.org/ Violence in West Africa (New York: International Rescue Committee, 2012). resources/4697, on May 20, 2015; Watts and Mayhew, “Reproductive Health Services and Intimate Partner Violence.” 6 WHO, Global and Regional Estimates of Violence Against Women.

INTIMATE PARTNER VIOLENCE AND FAMILY PLANNING: OPPORTUNITIES FOR ACTION www.prb.org 7 21 Hindin, Kishor, and Ansara, Intimate Partner Violence among Couples in 10 30 Rob Stephenson et al., “Physical Domestic Violence and Subsequent DHS Countries; Kishor and Johnson, “Profiling Domestic Violence”; Anita Contraceptive Adoption Among Women in Rural India”; Anita Raj et al., Raj and Lotus McDougal, “Associations of Intimate Partner Violence With “Associations of Marital Violence With Different Forms of Contraception: Unintended Pregnancy and Pre-Pregnancy Contraceptive Use in South Cross-Sectional Findings from South Asia,” International Journal of Asia,” Contraception 91, no. 6 (2015):456-63. Gynecology and Obstetrics (2015): doi: 10.1016/j.ijgo.2015.03.013. 22 Christine C. Pallitto and Patricia O’Campo, “The Relationship Between 31 Rob Stephenson et al., “Physical Domestic Violence and Subsequent Intimate Partner Violence and Unintended Pregnancy: Analysis of a National Contraceptive Adoption Among Women in Rural India”; Lauren Maxwell et Sample From Colombia,” International Family Planning Perspectives 30, no. 4 al., “Estimating the Effect of Intimate Partner Violence on Women’s Use of (2004). Contraception.” 23 WHO, Global and Regional Estimates of Violence Against Women; Chibber 32 Alio, “Spousal Violence and Potentially Preventable Single and Recurrent and Krishnan, “Confronting Intimate Partner Violence.” Spontaneous Fetal Loss in an African Setting”; Raj et al., “Associations of Marital Violence with Different Forms of Contraception.” 24 Heidi Stöckl et al., “Induced Abortion, Pregnancy Loss and Intimate Partner Violence in Tanzania: A Population Based Study,” BMC Pregnancy and 33 Megan Hall et al., “Associations Between Intimate Partner Violence and Childbirth 12, no. 12 (2012); Amina P. Alio, Philip N. Nana, and Hamisu M. Termination of Pregnancy: A Systematic Review and Meta-Analysis,” Salihu, “Spousal Violence and Potentially Preventable Single and Recurrent PLOS Med 11, no. 1 (2014): e1001581 ; Raj and McDougal, “Associations Spontaneous Fetal Loss in an African Setting: Cross-Sectional Study,” of Intimate Partner Violence with Unintended Pregnancy and Pre-Pregnancy Lancet 373, no. 9660 (2009): 318-24; Jay G. Silverman et al., “Intimate Contraceptive Use in South Asia.” Partner Violence and Unwanted Pregnancy, Miscarriage, Induced Abortion, 34 For more on universal screening, see www.igwg.org/ and Stillbirth Among a National Sample of Bangladeshi Women,” British Events/16DaysDec2014.aspx. Journal of Obstetrics and Gynaecology 114, no. 10 (2007): 1246-52. 35 Chi-Chi Undie et al., “Is Routine Screening for Intimate Partner Violence 25 Lauren Maxwell et al., “Estimating the Effect of Intimate Partner Violence on Feasible in Public Health Care Settings in Kenya?” Journal of Interpersonal Women’s Use of Contraception: A Systemic Review and Meta-Analysis,” Violence, accessed at www.popcouncil.org/research/is-routine-screening- PLoS ONE 10, no. 2 (2015): e0118234. for-intimate-partner-violence-feasible-in-public-healt, on July 2, 2015; Nicola 26 Lauren Maxwell et al., “Estimating the Effects of Intimate Partner Violence Christofides and Rachel Jewkes, “Acceptability of Universal Screening for on Women’s Use of Contraception”; Hindin, Kishor, and Ansara, Intimate Intimate Partner Violence in Voluntary HIV Testing and Counseling Services in Partner Violence among Couples in 10 DHS Countries; Amina P. Alio et al., South Africa and Service Implications,” AIDS Care 22, no. 3 (2010): 279-85. “Intimate Partner Violence and Contraception Use Among Women in Sub- 36 InterAgency Gender Working Group (IGWG) of USAID, Addressing Gender- Saharan Africa,” International Journal of Gynecology and Obstetrics 107, Based Violence Through USAID’s Health Programs: A Guide for Health no. 1 (2009): 35-8. Sector Program Officers, 2d ed. (Washington, DC: IGWG, 2008). 27 Kishor and Johnson, “Profiling Domestic Violence”; Silverman and Raj, 37 Lori Heise and Andreas Kotsadam, “Cross-National and Multilevel Correlates “Intimate Partner Violence and Reproductive Coercion.” of Partner Violence: An Analysis of Data From Population-Based Surveys,” 28 Rob Stephenson et al., “Physical Domestic Violence and Subsequent Lancet Global Health 3, no. 6 (2015): e332-40. Contraceptive Adoption Among Women in Rural India,” Journal of 38 Lori Michau, “Prevention of Violence Against Women and Girls: Lessons Interpersonal Violence 28, no. 5 (2013): 1020-39. From Practice,” Lancet 385, no. 9978 (2015): 1672-84. 29 E. Emenike, S. Lawoko, K. Dalal, “Intimate Partner Violence and 39 “Gender Equity Focused Family Planning Young Married Couples in Rural Reproductive Health of Women in Kenya,” International Nursing Review India (CHARM),” UC San Diego School of Medicine, accessed at http://gph. 55 (2008): 97-102. ucsd.edu/research/active-projects/Pages/gender-equity.aspx, on July 2, 2015; Anita Raj, “Engaging Men in Gender Equity Focused Interventions to Improve Sexual and Reproductive Health: Findings From India and the US,” paper delivered at the National Conference on Health and Domestic Violence, Washington, DC, March 19-21, 2015. 40 Tanya Abramsky et al., “Findings from the SASA! Study: A Cluster Randomized Controlled Trial to Assess the Impact of a Community Mobilization Intervention to Prevent Violence Against Women and Reduce HIV Risk in Kampala, Uganda,” BMC Medicine 12, no. 122 (2014). 41 CARE, “The Empower Project: Fostering Alliances for Action Against Gender Based Violence in Benin,” (2013), accessed at www.care.org/sites/default/ files/documents/GBV-2013-BEN-CARE-EMPOWER-Case-Study.pdf, on June 30, 2015.

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